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General NPI Number Information
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NPI Number | 1831470723
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Entity Type | Organization
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Legal Business Name | MARIO H IRIGOYEN LCSW - LLC
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Dates
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Enumeration Date | 09/06/2011
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Last Update Date | 09/06/2011
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Provider Practice Location Address
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Address Line | 61 GRAND AVE
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City | ENGLEWOOD
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State | NJ
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Zip | 07631-3572
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Country | US
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Telephone | 914-671-3924
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Fax | 845-942-1894
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Provider Business Mailing Address
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Address Line | 76 THIELLS RD
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City | STONY POINT
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State | NY
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Zip | 10980-3420
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Country | US
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Telephone | 914-671-3924
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Fax | 845-942-1894
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Authorized Official
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Title or Position | SOLE MBR
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Name | MR. MARIO H IRIGOYEN
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Credential | LCSW
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Telephone | 914-671-3924
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number | 44SC05377600
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License Number State | NJ
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